Key Messages
·
Maternal overweight and obesity,
advanced maternal age and maternal smoking are the highest ranking
modifiable risk factors for still birth
·
Rates of stillbirth are persistently higher in areas with high
levels of deprivation
·
Wales has highest
rates of smoking and obesity in pregnancy than any other UK
country
·
The cause of still
birth is unknown in the majority of cases. It is important to
understand the impact of smoking and obesity on still birth rates,
particularly in light of the known epidemiology of these risk
factors such as rising levels of obesity in the population, and the
higher rates of smoking in areas of deprivation.
·
Supporting women
to give up smoking during pregnancy through improved access to
advice and NHS Stop Smoking services, and implementation of the
NICE guidance systematically across Wales should be given the
highest priority by the NHS and partners
·
Women with a high BMI at the start of pregnancy should receive
clinical care in line with
NICE guidance6 and CMACE5 recommendations to
minimise risks to mother and baby. This should include dietary
interventions and advice on physical activity to minimise weight
gain, improving outcomes for the pregnancy and subsequent
pregnancies
·
The public health role of the midwife and maternity services is
vital to ensure the delivery of evidence based public health
interventions and partnership working to reduce the inequality that
exists in still birth rates and other maternal and neonatal
outcomes
·
Partnership programmes targeted at areas of high deprivation such
as Flying Start and Families First should ensure maternal obesity
and maternal smoking are given a high priority within their work
with communities and families. The NHS should work with
partners to ensure accessible services exist in communities
to support women before, during and after pregnancy
·
Many health factors such as smoking and
obesity in pregnancy are difficult to address once a pregnancy has
started. The profile of the importance of preconception advice and
support should be raised and opportunistic contacts with primary
care, family planning and sexual health services should be
maximised
·
A detailed study of stillbirths is required if we are to understand
the reasons for stillbirth and identify modifiable risk factors
that can be addressed to prevent them from occurring.
A confidential enquiry focused on
stillbirths is recommended, to gain insights into the main causes
of stillbirth, to identify avoidable causes and to recommend
improvements in clinical care and service provision.
Background
The still birth rate in Wales is about 5 per
1,000 births and the rate has remained steady over the last 5
years, (about 200 babies a year in Wales)1.
This is in contrast to the neonatal
mortality rate in Wales which has declined from 4.1 per 1,000 live
births in 1999 to 2.9 per 1000 live births in 2005 and has remained
around this rate for the last 5 years. In the majority of cases the
cause of stillbirth is not known. Stillbirth rates in Wales remain
higher than in other European countries1
Rates
of stillbirth are persistently higher in areas with high levels of
deprivation1,2.
Lifestyle factors are linked to deprivation and are an important
contribution to health inequalities. Rates of smoking and obesity
(both risk factors for stillbirth) have been shown to be higher in
areas with high levels of deprivation2.
A systematic review of major risk factors for
stillbirth in high income countries has identified maternal
overweight and obesity (body-mass index >25 kg/m2), advanced
maternal age and maternal smoking as the highest ranking modifiable
risk factors3. In the UK smoking accounts for up to 7%
of all stillbirths but it is estimated that in disadvantaged
populations maternal smoking contributes to up to 20% of
stillbirths1.
Smoking and obesity in particular have a
high prevalence in the population and not only impact on rates of
still birth, but are also linked to higher rates of miscarriage,
maternal death, neonatal deaths, admission to neonatal care and low birth weight. The impacts
on the use of maternity and neonatal services are
significant2. These findings highlight the importance of
public health initiatives to tackle smoking and obesity in women of
reproductive age
In this
paper we present the evidence for preventable risk factors
associated with stillbirth and make recommendations for addressing
these.
Smoking in pregnancy
Wales has higher rates
of smoking in pregnancy than any other UK country. Around a
quarter (26%) of mothers in the UK smoked directly before or during
their pregnancy. Smoking levels before or during pregnancy
were highest in Wales (33%) and lowest in England (26%).
Across the UK, one in eight mothers (12%) continued to smoke
throughout pregnancy, and were still smoking after the baby was
born. Mothers in Wales were most likely to smoke throughout
their pregnancy (16%)4.
Smoking in pregnancy
is linked to a range of poor outcomes for mother and baby,
including increased risk of stillbirth. A recent report by Public
Health Wales, prepared as part of the Early Years Pathfinder
Programme (see Appendix 2), has identified the population
attributable risks associated with smoking in pregnancy from the
available evidence4 (see Table 1). This evidence
suggests that 4-7% of all stillbirths can be attributed to maternal
smoking.
Table
1 – Outcomes associated with smoking during
pregnancy4
|
Outcomes associated with cigarette smoking during
pregnancy
|
Population attributable risk
(Proportion of outcomes that could be attributed to maternal
smoking in pregnancy based on data from studies carried out in the
UK.
|
|
Ectopic pregnancy
|
8%
|
|
Low birth weight
|
10%
|
|
Preterm birth
|
13%
|
|
Premature rupture of the membranes
|
11%
|
|
Placenta praevia
|
14%
|
|
Placental abruption
|
13%
|
|
Low birth weight
|
10% - 27%
|
|
Small for gestational age
|
25%
|
|
Stillbirth
|
4-7%*
|
|
Sudden Infant death syndrome
|
26%
|
|
Respiratory distress
|
10%
|
*Based
on results from a range of studies in high income
countries
The evidence review conducted
as part of the Public Health Wales report found that high quality
evidence exists to support the effectiveness of interventions for
promoting smoking cessation in pregnancy4. This
evidence base, set out in NICE guidance, is not currently being
fully implemented in a robust, coordinated and systematic way by
the NHS in Wales. The report makes a series of recommendations
including the need to ensure:
·
Smoking in
pregnancy is the highest priority area for public health action for
the NHS in Wales.
·
Health Boards,
Public Health Wales/Stop Smoking Wales and Welsh Government work
together in an integrated way to ensure the robust, systematic and
coordinated implementation of the evidence base on smoking in
pregnancy
The
recommendations arising from this report are being taken forward by
Public Health Wales, in partnership with Health Boards. It is vital
that these actions be prioritised by all partners and strongly
supported by Welsh Government to ensure systematic implementation
of NICE guidance and the development and implementation of better
service models to increase uptake of Smoking Cessation services by
pregnant women
Maternal
Obesity
Over half the
population of Wales are currently overweight or obese (BMI
>25). The 2010 Centre for Maternal
and Child Enquiries report Maternal Obesity in the UK found that
6.5% of pregnant women in Wales had a BMI of 35 or more, compared
to the UK average of 5% (see figure 1)5. Wales has the
highest prevalence of maternal obesity of all the UK
countries5. Obesity in pregnancy is currently one of the
biggest threats to maternal and child health in developed
countries. Women who are obese are more than twice as likely to
have a stillborn baby, and the risk increases with increasing
maternal BMI (see Table 2). Babies born to obese mothers are less
likely to be breast fed, more likely to have congenital anomalies,
especially neural tube defects, and to require admission to
neonatal units. It is also more difficult to monitor the health of
these babies during pregnancy and birth5.
The
mother’s
health is also at risk, as they are more likely to have
pregnancy-related complications such as gestational diabetes,
pre-eclampsia, haemorrhage following birth, thromboembolism and
deliver their babies by caesarean section5.
Figure 1: Rates
of Maternal Obesity in the UK
Source: CMACE 2010
Table 2: Fetal
Risks associated with Maternal BMI >30
|
Risk
|
Odds Ratio
|
|
Birth Defects
|
1.6
|
|
Prematurity
|
1.2
|
|
Macrosomia
|
2.4 – 3.1
|
|
Admission to NNU
|
1.3 – 1.5
|
|
Still Birth
|
2.1
|
|
Neonatal Death
|
2.6
|
Source:
CMACE
The recent CMACE 3
year study into maternal obesity in the UK, highlights the scale of
the issue and makes a series of recommendations in relation to the
safe clinical management of pregnant women with raised BMI in
pregnancy5. It is important that Health Boards are
taking forward these recommendations as part of clinical pathways
in order to ensure risks of still birth (and other adverse outcomes
associated with raised BMI) are minimised.
The Public Health
Wales Early Years pathfinder programme is currently preparing a
briefing paper, similar to that completed for Smoking in pregnancy
which will set out the epidemiology, evidence base, population
health impact and current situation in Wales in relation to
maternal obesity. It will be important for the NHS to work in
partnership to take forward these recommendations.
The Way
Forward
Still birth rates in
Wales have not fallen in recent years. In the majority of cases,
the cause of still birth is unknown. It is important to understand
the impact that some of these preventable risk factors are having
on still birth rates, particularly in light of the known
epidemiology of these risk factors such as rising levels of obesity
in the population, and the higher rates of smoking in areas of
deprivation. A confidential enquiry into still birth rates in Wales
would facilitate this understanding and identify areas for
improvement.
Supporting women to
give up smoking during pregnancy through improved access to advice
and services, and implementation of the NICE guidance
systematically across Wales should be given the highest priority by
the NHS and partners.
Women with a high BMI
at the start of pregnancy should receive clinical care in line with
NICE guidance6 and CMACE5 recommendations
to minimise risks to mother and baby. This should include
dietary interventions and advice on physical activity to minimise
weight gain, improving outcomes for the pregnancy and subsequent
pregnancies5,6.
The
public health role of the midwife and maternity services is vital
to ensure the delivery of evidence based public health
interventions and partnership working to reduce the inequality that
exists in still birth rates and other maternal and neonatal
outcomes such as miscarriage, low birth weight and pre term births.
There is a strong policy context for this7,8 and a high
priority should be given to ensuring staff working in maternity
services have the skills and time to deliver the public health
agenda.
Partnership programmes targeted at areas of high deprivation such
as Flying Start and Families First should ensure addressing
maternal obesity and maternal smoking is given a high priority
within their work with communities and families. The NHS should
work with partners to ensure accessible services exist in
communities to support women before, during and after pregnancy
It is vital for women to be healthy at
the start of pregnancy. This will significantly impact on the
outcome of the pregnancy for both mother and baby. Many
health factors such as smoking and obesity in pregnancy are
difficult to address once a pregnancy has started. It is more
effective if advice and behaviour change occur before conception.
The latest Centre for Maternal and Child Enquiries report on
maternal deaths highlights the benefits of providing targeted
support and pre-pregnancy counselling to women with epilepsy,
obesity, known significant mental ill health and congenital heart
disease9. Whilst this advice is available from all GPs,
midwives and health visitors there is a need for more proactive
targeting of this advice to those who need it most. The profile of
the importance of preconception advice and support should be raised
and opportunistic contacts with primary care, family planning and
sexual health services should be maximised.
Recommendations
arising from the work of the Early Years Pathfinder Programme will
support Health Boards in the implementation of the evidence base in
relation to maternal smoking, obesity and preconception.
References:
1.
Paranjothy S et al
2010. All Wales Perinatal Survey: Annual Report .
Department of
Child Health, School of Medicine, Cardiff University
http://www.cf.ac.uk/medic/awps/
2.
Public Health
Wales 2011. How are current and future population health needs
likely to impact on the use of maternity, neonatal, gynaecology and
paediatric service in North Wales; A population profile.
http://howis.wales.nhs.uk/sitesplus/888/news/39884
3.
Flenady V,
Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K, et al.
Major risk factors for stillbirth inhigh-income countries: a
systematic review and meta-analysis. Lancet
2011;377(9774):1331-40
4.
Public Health
Wales 2012. Smoking in pregnancy briefing paper, Reproductive and
Early Years Pathfinder Project.
5.
Centre for
Maternal and Child Enquiries 2010. Maternal Obesity in the UK:
findings of a national project. Available at:
http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/CMACE/CMACE_Obesity_Report_2010_Final%20for%20printing.pdf
6.
National Insitiute
for Health and Clinical Excellence 2010. Weight management before,
during and after pregnancy (PH27)
http://www.nice.org.uk/Search.do?searchText=weight+pregnancy&newsearch=true&x=16&y=8#/search/?reload
7.
Welsh Assembly
Government 2011b. A Strategic Vision for Maternity Services in
Wales - Draft Strategy Document. Available at:
http://wales.gov.uk/docs/dhss/consultation/110124summaryen.pdf
8.
Midwifery 2020
Programme. 2010 Public Health Workstream final report.
http://www.midwifery2020.org/Public%20Health/index.asp
9.
Centre for
Maternal and Child Enquiries 2011. Saving Mothers Lives: Reviewing
maternal deaths to make motherhood safer: 2006-08. The Eight Report
of the Confidential Enquiries into Maternal Deaths in the United
Kingdom. BJOG, Vol 118, Supplement 1
Appendix 1 – Background:
Public Health Wales
Public Health Wales is
an NHS organisation providing professionally independent public
health advice and services to protect and improve the health and
wellbeing of the population of Wales. Public Health Wales has four statutory
functions:
·
To provide and
manage a range of public health, health protection, healthcare
improvement, health advisory, child protection and microbiological
laboratory services and services relating to the surveillance,
prevention and control of communicable diseases;
·
To develop and maintain arrangements
for making information about matters related to the protection and
improvement of health in Wales available to the public; to
undertake and commission research into such matters and to
contribute to the provision and development of training in such
matters;
·
To undertake the
systematic collection, analysis and dissemination of information
about the health of the people of Wales in particular including
cancer incidence, mortality and survival; and prevalence of
congenital anomalies; and
·
To provide, manage, monitor,
evaluate and conduct research into screening of health conditions
and screening of health related matters.
Public Health Wales is currently
taking forward an Early Years Pathfinder Programme to drive
forward improvements in early years outcomes in Wales.
Appendix 2:
Smoking in Pregnancy: Briefing Paper
1
Background
The
prevalence of smoking in the female population and the variation of
smoking levels between the most and least deprived areas are
important factors influencing maternal and child health outcomes
within a population1. Maternal smoking is a key cause of
poor outcomes for mothers, babies and children. Smoking in
pregnancy is associated with increased risk of miscarriage,
perinatal death, prematurity, low birth weight and congenital
anomalies in the baby in particular of the heart, face and
limbs2. In developed nations, the single
most important factor that affects low birth weight is cigarette
smoking during pregnancy1,2.
Waleshas higher rates of smoking in
pregnancy than any other UK country. Around a quarter (26%)
of mothers in the UK smoked directly before or during their
pregnancy. Smoking levels before or during pregnancy were
highest in Wales (33%) and lowest in England (26%). Across
the UK, one in eight mothers (12%) continued to smoke throughout
pregnancy, and were still smoking after the baby was born.
Mothers in Wales were most likely to smoke throughout their
pregnancy (16%)3.
The smoking habits of teenage
girls are a particular cause for concern as smoking rates in this
group continue to increase despite a downward trend in all other
areas. This will have a direct impact on future smoking in
pregnancy rates2.
Supporting pregnant women to stop
smoking is a challenging area of public health and the numbers of
women supported by NHS stop smoking services is
low4,5. A study from Scotland found that in 2006
only 3.2% of identified pregnant smokers
quit5.
This briefing paper, developed as
part of the Public Health Wales, Reproductive and Early Years
Pathfinder Project, aims to give an overview of the evidence base
on what works to support pregnant smokers to quit, what the
implications would be for population health in Wales if this
evidence was implemented in a robust and systematic way and an
overview of how services are currently configured in Wales and
progress towards implementing evidence based practice. It is
hoped this paper will guide the future development of services and
support for pregnant women in order to maximise health outcomes for
mothers and babies.
Epidemiology of
cigarette smoking during pregnancy in Wales
Cigarette smoking
during pregnancy is associated with adverse perinatal outcomes for
the mother and baby as illustrated in Table 1 below.
Table 1 –
Outcomes associated with smoking during pregnancy
|
Outcomes associated with cigarette smoking during
pregnancy
|
Population attributable risk (Proportion of outcomes that
could be attributed to maternal smoking in pregnancy based on data
from studies carried out in the UK.
|
|
Ectopic pregnancy
|
8% (6)
|
|
Low birth weight
|
10% (6)
|
|
Preterm birth
|
13% (7)
|
|
Premature rupture of the membranes
|
11% (6)
|
|
Placenta praevia
|
14% (6)
|
|
Placental abruption
|
13% (6)
|
|
Low birth weight
|
10% (6), 27% (7)
|
|
Small for gestational age
|
25% (7)
|
|
Stillbirth
|
4-7%* (9)
|
|
Sudden Infant death syndrome
|
26% (6)
|
|
Respiratory distress
|
10% (6)
|
*Based on results from a range
of studies in high income countries9
The longer term
impacts on the child from smoking during pregnancy include
asthma10, upper respiratory infections10,
behavioural problems10, the effects of preterm birth
such as neuro-developmental problems11, the effects of
low birth weight such as coronary heart disease and diabetes in
adulthood11.
Women who did not
smoke during pregnancy were less likely to have a preterm birth
(5.9% vs. 8.2%) or to give birth to a low birth weight baby (5.5%
vs. 8.9%) than women who smoked at some time during the year before
birth(10). There was a reduction in the proportion
of preterm births (6.7% vs. 9.1%) and low birth weight infants
(7.9% vs. 9.6%) for women who quit smoking within the first
trimester, compared with women who smoked beyond the first
trimester(10). Women who smoked during the first
two trimesters of pregnancy had a 90% increase in risk for placenta
praevia (OR = 1.9 [95% CI, 1.2–3.0]) than women who did not
smoke during pregnancy(10). The risks of small for
gestational age births increased with the number of cigarettes
smoked during the third trimester. The impact of smoking on
low birth weight can be lessened if women quit before their third
trimester. Similarly, for studying fetal growth restrictions,
knowledge of smoking habits during the third trimester, the time
when most of the growth in the fetus occurs, is of critical
importance(10).
Emerging evidence
suggests that reducing exposure to smoke during pregnancy improves
outcomes at a population level, with a recent Scottish study
highlighting findings suggesting that the introduction of national,
comprehensive smoke free legislation was associated with
significant reductions in pre term births and babies being born
small for gestational age20
The UK Infant
feeding survey estimates 33% of women in Wales smoke before or
during pregnancy, and 16% smoke throughout pregnancy. This
varies according to social class with higher prevalence in lower
social classes. Across the UK, mothers in managerial and
professional occupations were the least likely to have smoked
before or during pregnancy (14%) whilst those in routine and manual
occupations were the most likely to have done so (40%).
Mothers in routine and manual occupations were five times more
likely than those in managerial and professional occupations to
have smoked throughout pregnancy (20% and 4%
respectively)3.
Estimation of
trends in cigarette smoking prevalence in Wales and in sub-sections
of the population are hampered by the lack of good quality
routinely collected information. Although all women are
usually asked at their antenatal booking appointment about
cigarette smoking and this information is recorded in their
hand-held antenatal notes, this is not consistently reported to the
local Child Health Systems across Health Boards, resulting in
patchy completeness of data collected at a national level within
The National Community Child Health Database (NCCHD) (Table
2). This data completeness issue is being addressed by an
ongoing data quality improvement agenda by the NCCHD Steering
Group. Further information of referral to smoking cessation
services, or smoking status during late pregnancy is not
recorded. It is important that we resolve these issues around
data quality and completeness at a national level to enable more
detailed analysis and social profiling of smoking during pregnancy
to inform the targeting of services.
Table 2 – Data completeness and maternal smoking prevalence
by Health Board, Wales
|
Health
Board
|
Total
births
|
Data completeness
(%)
|
Smoking prevalence
(%)
|
|
Cwm Taf
|
4253
|
94%
|
26%
|
|
BCU
|
6939
|
91%
|
21%
|
|
Hywel Dda
|
3438
|
52%
|
14%
|
|
ABMU
|
6365
|
23%
|
8%
|
|
CVU
|
6233
|
9%
|
99%
|
|
AB
|
6088
|
1%
|
14%
|
|
Powys
|
157
|
99%
|
21%
|
|
Source: NCCHD 2010
|
2
Methodology
Overview of the evidence
The overview of the evidence presented in this
paper was undertaken using a pragmatic high level search of key
sources.
The Public Health Wales ATTRACT team undertook a
series of literature searches to answer the following
questions:
·
What are the most
effective interventions to support women to stop smoking during
pregnancy?
·
How effective are
midwives at delivering smoking cessation interventions to pregnant
women?
·
What are the best
models of service delivery for smoking in pregnancy
services?
·
Are home visits to
support women to stop smoking in pregnancy more effective than
clinic based interventions?
·
How effective are
pharmacists in supporting pregnant women to give up
smoking?
In addition, the recently published National
Institute for Health and Clinical Excellence (NICE) public health
guidance 26 – How to stop smoking in pregnancy and following
childbirth4 was reviewed at length by the ATTRACT team
and authors of this paper, and the key findings from the NICE
evidence review are highlighted.
Impact of implementing the evidence
base on population health outcomes
The NICE Costing Template, a tool published as
part of the NICE guidance 26 was used to estimate the economic and
population health impact of smoking in
pregnancy.6. The template estimates the potential
number of cases and cost savings that would result in Wales,
assuming there is no difference in the prevalence of these outcomes
between England and Wales or uptake of smoking cessation
services. We acknowledge that this model is limited as it
does not take account of the wider health and social impacts of
cigarette smoking and at best will provide a conservative
estimate.
Overview on current service delivery
and outcomes in Wales
A mapping exercise was completed in August 2011
as part of the pathfinder project. This involved asking all
Health Board’s in Wales about the early years’
interventions currently in place. This included smoking in
pregnancy interventions and the mapping document is used to
describe current practice in Wales and progress with implementation
of the evidence base (Appendix 1). There were several
limitations to this exercise. It was extremely difficult to
compile a list of early interventions across Wales as there is no
system or resource that captures this information. Collecting
the information took a huge amount of chasing and the accuracy very
much depended on interviewing the right individual in each Health
Board about each intervention. Consequently there were some
gaps, and it isn’t possible to know if this is because
interventions are not in place or that the right individual was not
interviewed. Also the information provided by Health
Board’s was a snap shot, and developments in the individual
areas are happening all the time. Regular surveys would be
needed to capture progress on key programmes.
3
Overview of Evidence
Base
3.1
Effectiveness of smoking cessation
interventions in pregnancy
The evidence on the effectiveness of smoking
cessation interventions has recently been reviewed and described in
detail by NICE in public health guidance 26 – How to stop
smoking in pregnancy and following childbirth4.
The NICE evidence review found that there is high quality evidence
on the effectiveness of interventions for promoting smoking
cessation in pregnancy. A recently updated Cochrane review,
showed a significant
reduction in smoking in late pregnancy following interventions
(risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96),
an absolute difference of six in 100 women who stopped smoking
during pregnancy. When the review looked at the studies with
the lowest risk of bias only, the interventions had less effect (RR
0.97,95% CI 0.94 to 0.99). Using the results of this
systematic review it can be estimated that smoking cessation
interventions can reduce smoking in late pregnancy by
3-6%11.
The Cochrane review found that smoking cessation
interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to
0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there
was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean
birthweight. There were no statistically significant differences in
neonatal intensive care unit admissions, very low birthweight,
stillbirths, perinatal or neonatal mortality but these analyses had
very limited power. Appendix 2 gives a summary of the
evidence on effect sizes resulting from individual smoking
cessation interventions in pregnancy.
The Cochrane review concludes that smoking
cessation interventions should be implemented in all maternity care
settings and that population based measures to reduce smoking and
social inequalities should be supported11.
NICE reports good evidence to support that women
in the UK under report smoking and that CO monitoring can aid in
the identification of smokers and support referral into NHS
Stop Smoking Services4. The evidence supports the
role of NHS Stop Smoking Services and indicates that they are
effective in supporting women to stop smoking. Four UK
studies on outcomes, reported 4 week quit rates of 32-48% for
pregnant women using NHS Stop Smoking Services4. A
Scottish review of smoking cessation services for pregnancy did
find that there was large variation in the reach and effectiveness
of services, with some areas offering no tailored
support4.
The evidence supports
the use of self help interventions to aid cessation in pregnant
women, although the extent of UK evidence was found to be
limited4.
Effectiveness of Nicotine Replacement Therapy in Pregnancy
(NRT)
The NICE review found that there was mixed
evidence on the effectiveness of Nicotine Replacement Therapy (NRT)
in pregnancy4. The Cochrane review conducted a
meta-analysis on five trials and found NRT to be effective
(RR 0.95, 95% CI 0.92 to
0.98). However a subsequent meta-analysis carried out to
support development of the NICE guidance12 concluded
that the Cochrane review does
not provide the most accurate possible estimate for the safety and
effectiveness of NRT as:
·
A large double
blind placebo randomised trial has been published since and its
findings need to be considered.
·
The
Cochrane reviews synthesises data from trials with multi-modal
intervention strategies which often involve a number of different
interventions being delivered. Whilst this permits maximum
use of available research data, it is not necessarily an
appropriate strategy for determining the effectiveness of the
individual interventions.
·
Cochrane analyses
include one trial in which NRT was offered to women as part of a
multi-modal treatment strategy and in which the level of
behavioural support for smoking cessation offered in addition to
NRT in the intervention group was substantially higher than the
amount offered in the “routine care control
group”. As behavioural support is an effective
treatment for smoking cessation in pregnancy, the inclusion of this
trial has probably resulted in an over-estimate of the
effectiveness of NRT in both the current and previous Cochrane
reviews.
In the updated
meta-analysis12 findings of all trials suggest that NRT is
effective for reducing smoking in later pregnancy [RR, 95% CI =
0.92 (0.87, 0.98)], but that all of the evidence for NRT being
effective comes exclusively from the trials which are at highest
risk of bias (non-placebo randomised studies [RR, 95% CI = 0.87
(0.81, 0.94)]). The most robustly designed trials (placebo
randomised,) provide no evidence that NRT is effective for smoking
cessation in pregnancy [RR, 95% CI = 0.94 (0.87, 1.02)]. See
Appendix 3 for results of this meta analysis.
The NICE evidence briefing also concluded that
there is no evidence that NRT either increases or decreases low
birth-weight and that there are insufficient data to form
judgements about any impact of NRT on stillbirth or special care
admissions12. Consequently there is currently
insufficient evidence to conclude whether or not NRT is effective
when used in pregnancy. A recent large, double blind placebo
controlled trial of NRT in pregnancy conducted in England (SNAP)
found that adding a nicotine patch (15 mg per 16 hours) to
behavioural cessation support for women who smoked during pregnancy
did not significantly increase the rate of abstinence from smoking
until delivery or the risk of adverse pregnancy or birth outcomes.
However, low compliance rates substantially limited the assessment
of safety21
A statement from the UK teratology service on
the use of NRT in pregnancy states13:
“Tobacco use and exposure through passive
smoking during pregnancy is associated with an increased risk of
intrauterine growth retardation, cleft lip and/or palate, ectopic
pregnancy, spontaneous abortion, premature delivery, perinatal
mortality and poor postnatal development.
The first
choice treatment for tobacco use cessation during pregnancy would
be through cognitive behavioural therapy (CBT). In
non-pregnant populations, CBT combined with nicotine replacement
therapy (NRT) has been shown to increase rates of tobacco use
cessation.
Concerns
exist over the efficacy and safety of NRT in pregnancy. An
advantageous risk vs. benefit ratio has not, as yet, been
adequately proven, however use of NRT may be preferable to
continued fetal exposure to the many harmful constituents of
tobacco smoke. The available data which investigate pregnancy
outcomes, although limited, do not yet provide substantial evidence
of an increased risk of adversity when NRT has been used during
pregnancy.
Should CBT
measures fail to control a patient’s urge to use tobacco, NRT
could be considered provided concomitant tobacco use is kept to an
absolute minimum. When NRT is indicated it should be used at
the lowest effective dose which controls symptoms of withdrawal and
cravings”.
Effectiveness of financial incentives.
The NICE guideline
highlights that there is good evidence from the recent Cochrane
review to support use of financial incentives in promoting smoking
cessation in pregnancy. The meta analysis of the US based
trials found that financial incentives were significantly more
effective than other intervention strategies (RR 0.76, 95% CI 0.71
– 0.81)4,11. NICE state that rigorous
UK-based research is needed to take account of cultural differences
and stress the need to avoid a proliferation of local evaluations
which may be insufficiently powered or inappropriately designed to
determine whether incentives are effective4.
3.2
Barriers to smoking cessation in pregnancy
There have been a
number of qualitative studies looking at the barriers to pregnant
women stopping smoking4,11,14,15,16. The
professional barriers to supporting pregnant women to stop smoking
have been described as; health professionals not asking about
smoking status for fear of damaging the relationship with the
pregnant woman, limited knowledge on guidelines/protocols in place,
staff perception that they have limited skills and knowledge to
implement successful interventions, staff perception of lack of
time and staff perception of the limited effectiveness of
interventions4,11. It has been suggested that the use of Numbers Needed to Treat
(NNT) rather than absolute risk reduction data to express the
efficacy of smoking cessation in pregnant women could help to
overcome the pessimism of staff over the high failure rate.
Data from systematic reviews suggest NNT’s of between
17 and 3311 which could be used in conjunction with data
on success rates of NHS specialist services to encourage referral
by staff4,11.The barriers for pregnant women to stopping
smoking have been described as length of sessions, difficulty
making phone contact, lack of transport or child
care4,14,15. Home visits or very local services
and the provision of crèche facilities have been suggested as
possible service options in order to address some of these
barriers14. This is supported by NICE who
recommend that home visits or alternative venues should be
considered for those women who are reluctant to or find it
difficult to attend the clinic4. Fear of failure,
beliefs about control and concerns about being stigmatised have
also been described as important
barriers15,16.
Consideration should
be given to undertaking a social profiling exercise in Wales in
order to establish who the different groups of women who smoke are
and what are the individual motivations/barriers, in order to
target the evidence based interventions accordingly
3.3
Models of service delivery
Following an extensive review of the evidence,
NICE make the following recommendations in relation to the model of
service delivery that should be in place to support women to stop
smoking during pregnancy4:
Role of Midwives at booking and
subsequent appointments:
·
Assess
woman’s exposure to tobacco smoke through discussion and use
of CO monitoring.
·
Discuss health
risks, benefits of stopping smoking and provide
information.
·
Refer all pregnant
smokers, those with CO reading >7 ppm and those stopped in
previous two weeks to NHS Stop Smoking Services on opt out basis
using NICE referral pathway.
·
All midwives
should be trained in assessing and recording smoking status and
readiness to quit, discussing health risks and making a referral
into the local Stop Smoking Service. Midwives are not advised
to carry out brief interventions, but should use their skills to
initiate a referral into NHS Stop Smoking Services.
Other staff in wider
health care team (GP’s, Practice Nurses, HV’s,
Obstetricians, Paediatrician, Sonographers) should ask about
smoking status at every opportunity and refer those who want to
stop to the NHS Stop Smoking Service using local
arrangements4.
Role of NHS Stop Smoking Services:
·
Attempt to contact
woman by telephone twice and follow up with a letter.
·
Attempt to see
those who can’t be contacted by phone. For example in a
routine antenatal contact.
·
Address any
barriers to taking up smoking cessation services. Consider
offering home visits or alternative locations for those who are
reluctant or find it difficult to attend clinic.
·
Feedback on
individual clients should be given to the midwife.
·
Provide intensive
interventions and ongoing support throughout pregnancy and beyond
(as detailed in NICE guidance).
·
Discuss risks and
benefits of NRT.
·
For those women
who are disadvantaged, the service should be offered in a flexible,
client centred way. Interventions should be delivered in
locations and times that mean they are accessible and tailored to
individual needs. Services should work in an integrated way with
other services such as substance misuse and teenage pregnancy
support.
Evidence searches
were undertaken by the ATTRACT team in order to answer the
following questions:
·
What are the most
effective interventions to support women to stop smoking during
pregnancy?
·
How effective are
midwives at delivering smoking cessation interventions to pregnant
women?
·
What are the best
models of service delivery for smoking in pregnancy
services?
·
Are home visits to
support women to stop smoking in pregnancy more effective than
clinic based interventions?
·
How effective are
pharmacists in supporting pregnant women to give up
smoking?
These searches
found that there is limited high quality evidence that the site or
setting of the intervention influences the effectiveness of smoking
cessation interventions for pregnant women in the UK. There
also appears to be little high quality evidence in relation to
effectiveness of midwives in delivering the intensive support as
part of the Stop Smoking team. The ATTRACT team found three
papers5,17,18 describing midwives delivering
interventions, as part of the service. Two of these were
evaluations of service delivery and one was an RCT of motivational
interviewing approaches by midwives, which did not show significant
increases in smoking cessation. NICE highlight that where
midwives do deliver the intensive interventions they should be
trained to the same standard as NHS stop smoking
advisors4.
There are a number of published evaluations of
outcomes for smoking in pregnancy services in the UK. One
mixed methods evaluation undertaken in Scotland found that most
stop smoking services in Scotland offered home visits by trained
advisers to pregnant women. An analysis of routine service
data, suggested that for home based services for which data on
engagement (whether a woman attended the first appointment with a
specialist advisor) were available, about 50% of those referred
engaged compared with 20% for clinic-based
services19.
An evaluation undertaken on the three beacon
services in England found that those services that were delivering
the best outcomes had several common
features17;
·
Interventions
delivered by small number of dedicated clinical staff (nurses or
midwives)
·
Full support from
Heads of Midwifery
·
Receive bulk of
referrals from midwives
·
Offer NRT to
almost all pregnant smokers and have an efficient system for
providing the prescriptions (eg PGD’s)
·
Offer flexible
home visits
·
Provide intensive
multi session treatment delivered by small number of full time
staff
Another evaluation of
a service for young pregnant smokers highlighted the importance of
good integration between maternity services and Stop Smoking
Services. Although numbers participating were small, the
project pointed to the value of midwife led home visits in engaging
this group of women18.
An observational
study undertaken in Scotland, using routinely collected data found
that a very low proportion of pregnant smokers are supported to
quit in Scotland (3.2%)5. Poor outcomes were
attributed to issues along the whole pathway in relation to
identification, engagement and treatment5. The
study suggests CO monitoring can be useful in encouraging midwives
to ask about smoking and in addressing under reporting. A
greater proportion of women set a quit date and quit when
interventions were delivered at home. Costs were higher with
home visits5.
The ATTRACT team
found very little evidence on the effectiveness of pharmacists in
supporting pregnant women to stop smoking. This is one of a
number of areas identified as needing further research.
3.4
Population health and economic impacts of implementing evidence
base on smoking cessation in pregnancy
Using the NICE
costing template it is possible to model the population health and
economic impacts of increasing the uptake of women receiving NHS
stop smoking support6. Table 3 models how many
more women could be supported to quit in Wales if the uptake of
smoking services increased to 25%. There are several
assumptions that have been used in this model. Smoking
prevalence is assumed to be 33%, taken from the infant feeding
survey3 and the current uptake of pregnant women
receiving support has been estimated at 11% using data from NHS
Stop Smoking services in England. Data from one Health Board in
Wales suggests that uptake of Stop Smoking Services by pregnant
women is currently a lot lower than England (<5%). More
work is being done to develop more robust data on uptake at an all
Wales level. A sensitivity analysis has been carried out to model
the assumptions at different levels of smoking prevalence and
uptake of smoking cessation services (see Appendix 4)
Table 3 Service delivery Statistics
– Local assumptions
|
|
Percentage
|
Number of people
|
|
Number of pregnant women
|
100%
|
34937
|
|
Smoking prevalence in
pregnancy1
|
33%
|
11529
|
|
Current uptake of pregnant women receiving NHS
stop smoking support2
|
11%
|
1268
|
|
Future uptake of women receiving NHS Stop
Smoking support3
|
25%
|
2882
|
|
Additional pregnant women receiving NHS
support
|
14%
|
1614
|
|
Number of women successfully quitting smoking as
a result of contact with NHS services4
|
45%
|
726
|
|
Pregnant women who stopped as a % of all women
who smoke5
|
6.3%
|
726 / 11,529
|
|
Estimated number of births to women who
smoke
|
33%
|
11,529
|
1.
This is the percentage of women who smoked before or during
pregnancy in Wales in 2010 from the Infant Feeding Survey
2010
http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/IFS_2010_early_results/IFS_2010_headline_report_tables2.pdf
2.
This is an estimate based on 188,023 pregnant women smoking in
England (26% of 723,165 live births) in England in 2010 and
21,839 pregnant women in England setting a quit date in 2010/11
from Statistics on NHS Stop Smoking Services: England, April
2010-March 2011
http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/NHS%20Stop%20Smoking%20Services%20201011/SSS_2010_11.pdf
3.
This is an estimate for future uptake of NHS Stop Smoking
services
4.
This is an estimate for Wales based on the percentage of pregnant
women who are successful quitters at 4 weeks in England from the
NHS Stop Smoking Services report above. The number is 45% of
2306, the additional women who contact Stop Smoking Services if
uptake is increased to 25%.
5.
This is calculated by taking 1,038 as a percentage of 11,529, the
number of additional quitters as a percentage of those women who
smoke during pregnancy.we have used the number of live
births
6.
The number of pregnant women was taken as the number of live
births, so the number of births to women who smoke is the same as
the number of pregnant women who smoke.
Assuming that the prevalence of the
complications is the same in Wales as in England, the following
table estimates the number of cases with infant and maternal
complications. It also estimates the number of cases due to
smoking using Population Attributable risks. If the uptake of
stop smoking services for pregnant women increased to 25% then it
is estimated that 6.3% of all pregnant women who smoke will quit.
Population Attributable risks have been calculated from these
figures and used to estimate the number of complications due to
smoking. The calculations below estimate that an uptake of 25%
would result in 234 out of 3368 maternal or infant complications
being avoided.
Table 4 Maternal and infant
complications: general cases in pregnancy and associated cases due
to smoking.
|
|
Estimate of number of cases
based on births1
|
Cases due to
smoking
|
|
Maternal
Complications
|
Ectopic pregnancy
|
182.80
|
9.71
|
|
Premature rupture of
membranes
|
1045
|
79.23
|
|
Placenta Praevia
|
70
|
7.32
|
|
Abruption placenta
|
43
|
3.97
|
|
Pre-term delivery
|
614
|
46.46
|
|
Pre-eclampsia
|
214
|
-5.56
|
|
Total Maternal
complications
|
2171
|
141.01
|
|
Infant
Complications
|
Low birth weight
|
791
|
55.56
|
|
Respiratory
distress
|
336
|
23.62
|
|
Sudden Infant Death Syndrome
(SIDS)
|
70
|
13.71
|
|
Total Infant
complications
|
1197
|
92.89
|
|
|
Total
|
3368
|
233.89
|
|
|
Total cases that could be
avoided
|
|
234
|
These calculations estimate that £443,064
could be saved in a year in Wales if uptake of stop smoking
services for pregnant women increased to 25%. This is
illustrated in Table 5. The NICE costing templates are set up
to calculate direct costs to NHS, they do not take into account the
medium and long term implications of some of these complications.
The overall cost to society from smoking and pregnancy will be
higher. An economic evaluation of smoking in pregnancy undertaken
to support the NICE review found that all effective interventions
were shown to reduce costs and increase Quality Adjusted Life Years
(QALY), for both the mother and the child22.
Furthermore, at a societal level, the net benefit (i.e. accounting
for money and health gains), could be in excess of £500
million22.
Table 5 Savings from cases of
maternal and infant complications avoided
|
|
Cases due to
smoking
|
Unit cost £
1
|
Total cost £
|
|
Maternal
Complications
|
Ectopic pregnancy
|
9.71
|
1081
|
10497
|
|
Premature rupture of
membranes
|
79.23
|
2679
|
212257
|
|
Placenta Praevia
|
7.32
|
2679
|
19610
|
|
Abruption placenta
|
3.97
|
2679
|
10636
|
|
Pre-term delivery
|
46.46
|
2679
|
124466
|
|
Pre-eclampsia
|
-5.68
|
2679
|
-15217
|
|
Total Maternal
complications
|
141.01
|
|
362,249
|
|
Infant
Complications
|
Low birth weight
|
55.56
|
870
|
48337
|
|
Respiratory
distress
|
23.62
|
870
|
20549
|
|
Sudden Infant Death Syndrome
(SIDS)
|
13.71
|
870
|
11928
|
|
Total Infant
complications
|
92.89
|
|
80,814
|
|
|
Total savings
|
233.9
|
|
443,064
|
1 The unit costs
are based on the NHS national tariff for 2010/11
The limitations of
the NICE costing models for public health interventions are a
subject of debate particularly due to the difficulty of obtaining
robust utility scores for use in cost-effectiveness models.
Further work is required to develop a more robust model that
addresses the current limitations.
4.0 What is
currently happening in Wales?
The mapping exercise
carried during 2011 and completed in Aug 2011 asked all Health
Boards in Wales to report progress on Smoking in Pregnancy.
Three out of seven Health Boards reported to have the NICE
opt out referral pathway in place, with one additional Health Board
reporting that it is in place in 1 out of 3 of the locality areas.
Three out of seven Health Boards reported having a lead
midwife identified to champion implementation of the NICE guidance
and act as a link between Stop Smoking Wales and the maternity
service. One additional Health Board reported that this is in
place in 1 out of 3 of the locality areas. Two out of seven
Health Boards reported having bespoke smoking in pregnancy training
for midwives in place (See Appendix 1). There were some
limitations to this exercise (see methodology section) and caution
should be applied to the interpretation of these findings.
In relation to the
delivery of interventions to pregnant women by Stop Smoking Wales,
the service currently offers the following:
·
Referrals received
by SSW from midwives. Advisors contact the pregnant women to
discuss benefits of quitting, offer support and arrange assessment
session
·
SSW attempt to
contact client twice by telephone, and send follow up letter if no
response. Clients are fast tracked into an appointment to
allow for the longest cessation period during their
pregnancy
·
Clients are
offered sessions for intensive support at existing community based
groups, on a one to one basis at a clinic/venue where SSW usually
hold sessions, or support over the phone.
·
Women are given 7
sessions of intensive support. If the client feels they are not
ready to quit at the assessment session there is a four week
flexibility within which time treatment can start.
·
Risks/benefits of
NRT are discussed in the sessions.
·
If the client
requires additional support following the seven sessions, the
advisor will arrange to telephone in two weeks time to check
progress.
There are several areas in relation to the service delivery model
that are recommended by NICE that are not currently being
implemented in Wales. These are:
·
Carbon monoxide
monitoring is not done routinely in Wales as part of the booking
visit and NICE referral pathway.
·
No attempts are
made to see women i.e in antenatal clinics, if they are unable to
be contacted by SSW.
·
Women are not
currently supported throughout their pregnancy and after
delivery.
·
There is variable
practice in relation to feedback on the progress of individual
clients from SSW to midwives.
·
There is currently
very little flexibility in the model of support for pregnant women
in relation to offering sessions at home or at alternative venues
for women who are disadvantaged, are reluctant or find it difficult
to access the services on offer.
5.0
Conclusions
Smoking in pregnancy is a major preventable
cause of poor outcomes and inequalities in maternal and child
health in the short, medium and long term. Wales is doing worse
than any other UK country in relation to the number of women that
continue to smoke throughout pregnancy.
High quality evidence exists to support smoking
cessation interventions in pregnancy, and there are key
recommendations from NICE highlighting what NHS and partners should
be providing as part of an effective, cost effective integrated
system to support women to stop smoking during pregnancy.
This evidence base is not currently being fully implemented
in a robust, coordinated and systematic way across by the NHS in
Wales.
Smoking in pregnancy is an extremely challenging
area of public health. Evidence on the barriers to smoking
cessation in pregnancy suggests that pregnant smokers are different
to other adult smokers who are motivated to quit and self refer to
SSW. There are practical issues with access to services, such
as childcare. Rurality is a big issue for the population in
Wales and services such as smoking cessation services need to be
provided as locally as possible. In addition, stigma, beliefs
about control and the fear of failure are often reported by
pregnant women as barriers to engaging with smoking cessation
services. The NICE guidance and evaluations of services from
other UK countries suggest that a flexible approach is needed for
pregnant women, particularly those who are disadvantaged, with the
services being offered in a client centred way throughout pregnancy
and following childbirth.
Flexibility may also be required in relation to
thinking about innovative and alternative ways to decrease levels
of smoking in pregnancy at a population level, including the role
of joint working with Welsh Government and agencies such as ASH
Wales. There may be a number of different ways to support
pregnant women to stop smoking. Strong evidence is emerging
on financial incentive schemes which highlight an urgent need to
evaluate these schemes in a UK setting. Other health
professionals, such as pharmacists or other primary care staff, may
have a role, particularly in rural or remote areas. Again,
this needs further research. There are a number of areas
where we don’t have high quality evidence to support practice
such as the site or setting of the interventions or the
professional delivering the interventions (i.e. midwife vs. smoking
cessation advisor). There are evaluations from England and Scotland
that suggest that flexibility around the site and setting and
clinical staff delivering the intervention can improve engagement
with the client, facilitate access to NRT and subsequently improve
outcomes; further high quality evidence is needed on
this.
6.0
Recommendations
The following are the key recommendations
arising from this paper:
·
Due to level of
harm to maternal and child health, and the evidence on
effectiveness of cessation, smoking in pregnancy should be the
highest priority area for public health action for the NHS in
Wales.
·
Health Boards,
Public Health Wales/Stop Smoking Wales and Welsh Government should
work together in an integrated way to ensure the robust, systematic
and coordinated implementation of the evidence base on smoking in
pregnancy. In particular ensuring:
o
Strong leadership
from maternity services with a senior midwife identified in each
Health Board area to work with Public Health Wales and Stop Smoking
Wales to implement the evidence base4.
o
Opt out referral
pathways based on NICE guidance in place in each Health Board area
to facilitate referral of all pregnant smokers into
SSW4.
o
CO monitors are
routinely used as part of the NICE referral
pathway4.
o
Access to bespoke
smoking in pregnancy training for midwives and support staff in all
Health Boards4.
o
A review of the
service model delivered by SSW to pregnant smokers, ensuring
implementation of evidence base in order to maximise
outcomes.
o
A review of the
availability of accurate data in order to establish the baseline,
monitor outcomes and the impact of service changes.
·
NHS and partners
in Wales need to urgently consider areas for innovation and
evaluation. Section 7 of this report includes areas for potential
research and evaluation within smoking cessation in
pregnancy.
·
Consideration
should be given to undertaking a social profiling exercise in Wales
in order to establish who the different groups of women who smoke
are and the differentials in uptake and
prevalence among different socio-economic groups. Including what are the
individual motivations/barriers, in order to target evidence based
interventions accordingly.
·
Consideration
should be given to how the NHS works in a more and integrated way
on this key priority area, with a seamless approach to joint
working across all NHS services and partner agencies. In
particular the value of working with other agencies such as ASH
Wales needs to be explored.
7.0 Areas for
further research
This evidence review
and that undertaken by NICE highlighted a number of important areas
that require further high quality research to be undertaken in
order to determine effectiveness:
·
Site or setting
used to deliver interventions for pregnant women.
·
Financial
incentive schemes in a UK setting.
·
Increasing contact
of smoking cessation services with pregnant women who
smoke.
·
Role of
pharmacists in supporting pregnant women to stop.
·
Self help
interventions in a UK setting.
·
How and why some
women spontaneously quit smoking when they become
pregnant
·
Interventions
across different socio-economic groups
References
1.
Public Wales 2011.
How are current and future population health needs likely to impact
on the use of maternity, neonatal, gynaecology and paediatric
services in North Wales? – A population profile.
http://howis.wales.nhs.uk/sitesplus/888/news/39884
2.
Betsi
Cadwaldr
University Health Board 2011. Executive
Director of Public Health Annual Report: The Importance of the
Early Years.
http://www.wales.nhs.uk/sitesplus/861/document/179011
3.
NHS Information
Centre 2011. Infant Feeding Survey: Early results. Available
at:
http://www.ic.nhs.uk/pubs/infantfeeding10
4.
NICE, PH26 How to stop smoking in
pregnancy and following childbirth, 2010, http://guidance.nice.org.uk/PH26
5.
Tappin DM,
MacAskill S, Bauld L, Eadie D, Shipton D, Galbraith L. Smoking
prevalence and smoking cessation services for pregnant women in
Scotland. Subst Abuse Treat Prev Policy. 2010 Jan
21;5:1.
6.
National Institute
of Health and Clinical Excellence (NICE) 2010. PH26 Quitting
smoking in pregnancy and following childbirth: costing template.
[Online]. Available at
http://guidance.nice.org.uk/PH26/CostingTemplate/xls/English
[Accessed 20
August 2010].
7.
Delpisheh A,
Kelly Y,
Rizwan S,
Attia E,
Drammond S,
Brabin BJ. Population attributable risk
for adverse pregnancy outcomes related to smoking in adolescents
and adults. Public Health 2007;121:861-8.
8.
Ananth CV, Smulian
JC, Vintzileos AM. Incidence of placental abruption in relation to
cigarette smoking and hypertensive disorders during pregnancy: A
meta-analysis of observational studies. Obstetrics and
Gynecology 1999;93:622-8.
9.
Flenady V,
Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K et al. Major
risk factors for stillbirth in high-income countries: a systematic
review and meta-analysis. Lancet
2011;377:1331-1340
10.
US DHHS 2004 U.S.
Department of Health and Human Services. The health consequences of
smoking: Chapter 5 Reproductive effects. 2004 Surgeon
General’s Report. U.S. Department of Health and Human
Services, 2004
11.
Lumley J,
Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L.
Interventions for promoting smoking cessation during pregnancy.
Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.:
CD001055. DOI: 10.1002/14651858.CD001055.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001055.pub3/pdf
12.
Bauld L,
Coleman T, The Effectiveness of Smoking Cessation Interventions
during Pregnancy: A Briefing Paper, 2009, http://www.nice.org.uk/nicemedia/live/13023/49422/49422.pdf
13.
UK Teratology Service, Use of nicotine replacement therapy
in pregnancy (Jun, 2011)
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Drugs-in-Pregnancy/Use-of-nicotine-replacement-therapy-in-pregnancy/?id=761534
14.
Tod, A. M.
& Tod, A. M. 2003, "Barriers to smoking cessation in pregnancy:
a qualitative study", British Journal of Community Nursing,
vol. 8, no. 2, pp. 56-64.
15.
Taylor, J,
Glazebrook, C, Coleman, T and Thornton, J (2008) Pregnant
women’s beliefs about NHS stop smoking services.
Psychology and Health 23251, Red ID 12 (conference
abstract).
16.
Ussher, M,
Aveyard, P, Coleman, T, Straus, L, West, R, Marcus, B, Lewis, B and
Manyonda, I (2008) Physical activity as an aid to smoking cessation
during pregnancy: two feasibility studies, BMC Public
Health, 8, 328, doi: 10.1186/1471-2458-8-328.
17.
Lee, M,
Hajek, P, McRobbie, H and Owen, L (2006) Best practice in smoking
cessation services for pregnant women: results of a survey of three
services reporting the highest national returns and three beacon
services, Journal of the Royal Society for the Promotion of
Health, 126, 233-238
18.
Bryce A,
Butler C, Gnich W, Sheehy C, Tappin DM. Midwifery. 2009
Oct;25(5):473-82. Epub 2008 Feb 14. CATCH: development of a
home-based midwifery intervention to support young pregnant smokers
to quit.
19.
Macaskill, S,
Bauld, L, Eadie, D and Tappin, D. (2008) Smoking Cessation
Support in Pregnancy in Scotland, Health Scotland,
Glasgow.
http://www.healthscotland.com/documents/2665.aspx
20.
Mackay DF,
Nelson SM, Haw SJ, Pell JP (2012) Impact of Scotland's Smoke-Free
Legislation on Pregnancy Complications: Retrospective Cohort Study.
PLoS Med 9(3): e1001175.
doi:10.1371/journal.pmed.1001175
21.
Coleman
T,
Cooper
S,
Thornton
JG,
Grainge
MJ,
Watts
K,
Britton
J,
Lewis
S;
Smoking, Nicotine,
and Pregnancy (SNAP) Trial Team(2012) A randomized trial of
Nicotine replacement patches in pregnancy. N Engl J Med.
2012 Mar
1;366(9):808-18.
22.
York Health Economics Consortium/ National
Institiute for Health and Clinical Effectiveness (2009) Economic
Analysis of Interventions for Smoking Cessation aimed at pregnant
women.
http://www.nice.org.uk/nicemedia/live/13023/49421/49421.pdf
Appendix 1 – Mapping of Smoking in Pregnancy Interventions in
Health Boards across Wales
|
Health Boards (HB)
|
Progress
with maternal smoking interventions
|
|
HB
A
|
-
Smoking
Cessation in pregnancy implementation group in place
-
BI Training
programme for midwives/HVs set up
-
Lead midwife
identified
-
NICE Pathway
agreed
-
Fax referral
mechanism has commenced
-
Systems for
data sharing between Stop Smoking Wales & midwives are starting
to be set up
|
|
HB
B
|
-
Smoking and
Maternity Smoking Cessation agreed as an outcome to ‘Smoke
Free UHB’ Action Plan 2010-2011
-
Midwifery
Service has agreed to implement the SSW Maternity Smoking Cessation
Programme and use the ‘opt out’ referral form at
booking appointment which is carried out in a hospital
setting
-
Agreed to use
SSW standardised ‘opt out’ referral form but want
additional ‘carbon copies’ added to this
-
Lead Midwife
agreed
-
2
Brief Intervention for Smoking Cessation Training Courses held for
Midwifery Care Assistants (MCAs) (who carry
out ‘booking’ clinics) and
Community Midwives.
-
Programme
officially launched February 2011
Smokebugs, Assist and Smokefree Class
Competition initiatives in place for generic smoking
prevention
|
|
HB
C
|
-
Locality
1
o
Brief Intervention Training
delivered to:
§ 1st, 2nd and 18
month undergraduate student midwives at Swansea University August
2010, and a lecture was given to the new 1st year intake
in December 2010
§ Teenstart Team (Midwives, Health visitors,
Students, Community Nurses, Link Workers, etc.
o
Awareness Raising Session delivered
to Antenatal Day Assessment Unit
-
Locality
2
o
Task and Finish group
established
o
Awareness Raising Session delivered
to Community Midwives and staff
o
Launch of maternity referral pathway
– August 2010 and ongoing
-
Locality
3
o
Deputy Head Midwife – Lead,
member of Task and Finish Group
o
Raising Awareness Sessions currently
being delivered by SSW Practitioner
o
Awaiting launch of referral
pathway
|
|
HB
D
|
-
Working with
Stop Smoking Wales
-
Training in
how to deliver ‘brief interventions for smoking
cessation’ delivered to Sure Start Health Visitors
Midwives provide systematic brief
interventions for smoking cessation
|
|
HB
E
|
-
Direct referral pathway in place to
SSW
-
Bespoke training delivered to
midwifery staff. BI training programme for midwife/HV
available
-
Consultant midwife lead
identified
-
Systems for
data sharing between SSW & midwives currently being
established
Pharmacy-based generic community
smoking cessation scheme also open to pregnant women
|
|
HB
F
|
-
Working with SSW for individual
referrals.
-
Roll out of National Smoking
Cessation Pathway
All Midwives & Health Visitors
give information and support/ signposting to cessation services and
inform about the risks of passive smoking with infants.
|
|
HB
G
|
Routine referral to Stop Smoking
Wales but no follow-up undertaken
|
Appendix 2
– Overview of evidence base on effect sizes of smoking
cessation interventions in pregnancy
